Speaker 1: Let's talk about it. Let's talk about the may Hero.
Speaker 1: Let's talk about it. Let's talk about the man hero.
Speaker 2: Welcome to the Welcome back to the mailroom, everybody.
Speaker 3: We are here with Jordan run Todd.
Speaker 2: I'm also joined by Professor Matt Ziegelman from the Mayo
Speaker 2: Clinic in Rochester, Minnesota.
Speaker 3: And before I get into that.
Speaker 2: I just want to reorient people that were in the
Speaker 2: middle of our series on Peroni's disease. We've had some
Speaker 2: natural history disease, state who gets it, how do we
Speaker 2: get it?
Speaker 3: What are the treatments?
Speaker 2: And the reason that I'm bringing in Professor Ziegelman is
Speaker 2: because he is really one of the most renowned surgeons
Speaker 2: in the country and therefore really in the world on
Speaker 2: dealing with some of the more complex cases of Pirnie's
Speaker 2: disease in the OAR and Matt and I have shared
Speaker 2: and and have talked back and forth about some of
Speaker 2: the more complicated cases that we've dealt with over our careers,
Speaker 2: and so he's a wonderful resource for me as a
Speaker 2: surgeon surgeon but also is able to break down some
Speaker 2: of the crazy things we're going to be talking about today.
Speaker 2: Because when I think about surgery for Prayerroni's, especially the
Speaker 2: more involved ones. It is some of the most delicate
Speaker 2: surgery we do in all of medicine. I mean, you
Speaker 2: think about spine surgery, sure, you think about neurosurgery, sure,
Speaker 2: But for us to be able to do a really
Speaker 2: good job on a Peroni surgery where we're the granddaddy
Speaker 2: of them all, which I'm sure we'll get into something
Speaker 2: called a plaque dexcision and graft, we essentially have to Jordan,
Speaker 2: I'm glad you're sitting down for this, and if you
Speaker 2: want to take some Sofran, now is the time to
Speaker 2: do it, because I know you get a little queasy.
Speaker 2: But we essentially have to disassemble most of the penis
Speaker 2: to fix the disease state and then reassemble it. And
Speaker 2: you got to do everything perfectly in order for a
Speaker 2: guy to have a good outcome. And so we're going
Speaker 2: to break down that as well as just kind of
Speaker 2: what we guys have to go through to get to
Speaker 2: that state, as well as what are the options and surgery.
Speaker 3: So, Matt, how's it going.
Speaker 2: I'm going to introduce you here in a second, but
Speaker 2: you look like you're in your your coat, You're in
Speaker 2: your scrubs like me.
Speaker 3: So it looks like we both have an our day
Speaker 3: to day.
Speaker 4: I'm I just did a consult. I'm actually on admin today,
Speaker 4: so this is a nice, perfect opportunity. But yeah, I'm
Speaker 4: really grateful for this opportunity. I've been I've been listening
Speaker 4: enthusiastically to your podcast. Here. What an honor to be here.
Speaker 2: Oh come on, now, this is great, I mean an
Speaker 2: honor for you. This is Matt Ziegelman here, professor of
Speaker 2: Urology at Mayo Clinic. He grew up born and raised
Speaker 2: really in the great state of North Dakota and went
Speaker 2: to North Dakota State along with Phil Jackson, Carson Wentz,
Speaker 2: who else am I forgetting? I mean notable alumni, including
Speaker 2: you professor here theoclinic. But he's also been really trained
Speaker 2: at some of the better programs in the country, including
Speaker 2: doing his fellowship in Male sexuals Dysfunction at RUSH in
Speaker 2: Chicago with Larry the Vine of the one of the
Speaker 2: giants in our field.
Speaker 3: As well.
Speaker 2: He is on the board of directors for the Sexual
Speaker 2: Medicine Society of North America, which was one of our
Speaker 2: premier and actually the premier section medicine society really in
Speaker 2: the country and therefore also in the world along with
Speaker 2: the International Society of Sexual Medicine. I shot out these
Speaker 2: guys all the time and the work they do, and
Speaker 2: he's really fully, fully, so focused. We'll fix that one
Speaker 2: and post solely focused. Now, don't just let her up.
Speaker 2: He is solely focused. One of the rare guys like
Speaker 2: me really that just do sexual medicine in men's health
Speaker 2: and perone's disease. And being at the Mayo Clinic, I'm
Speaker 2: sure he's seen a lot of cases that really very
Speaker 2: difficult for anybody else to take care of. So that's
Speaker 2: why I brought you in, Professor Ziegelman, to talk to
Speaker 2: us about some of the surgical management since we've we've
Speaker 2: gone over interleagional therapy. But I'll get your I'll get
Speaker 2: your opinion on that because one of the things that
Speaker 2: I really want to really start with is if we're
Speaker 2: if we look at what we always say, the pills
Speaker 2: and pokes and procedures of Payerne's disease, that's another four piece,
Speaker 2: like we have the five piece of the pinocalypse. Now
Speaker 2: we have bills, folks, procedures Payne's. But but you know,
Speaker 2: how does a guy get to your OAR. I think
Speaker 2: it's one of the things that we're going to unpack.
Speaker 2: But let's start with that. When you see a guy
Speaker 2: and you're counseling him and say, he's already seen like
Speaker 2: many of your patients, three or four other urologists, and
Speaker 2: he comes in and says, Professor Ziegelmann, I want you
Speaker 2: to operate on me.
Speaker 3: How does that conversation start.
Speaker 4: Yeah, a great question. I still like to start from scratch,
Speaker 4: to be honest. I mean, when I see my patients,
Speaker 4: it's tell me you know when this started, Like catch
Speaker 4: me up to speed. The is the phrase I like
Speaker 4: to use. And then I do a formal assessment in
Speaker 4: the office and then we start the conversation with I
Speaker 4: know you've been through some of these options. I know
Speaker 4: you've talked through other options with other clinicians. But let
Speaker 4: me just tell you what I think about traction. Let
Speaker 4: me tell you what I think about injections, let me
Speaker 4: tell you what I think about surgery specific to your case.
Speaker 4: And I think it's important to just emphasize to our
Speaker 4: patients that we are multifacet in our approach. And I
Speaker 4: just don't want somebody to think that even if they
Speaker 4: come in asking for surgery that I'm that's all that
Speaker 4: we have to offer. If nothing out that nothing else,
Speaker 4: excuse me. That just builds trust that we are in
Speaker 4: this together and we're you know, we're not just out there,
Speaker 4: you know, willy nilly cutting on.
Speaker 2: As Yeah, I think that's I mean, that's especially with
Speaker 2: Perroni's surgery, where side effects and the adverse events are
Speaker 2: are high. And you know, we we joke that if
Speaker 2: if you're a hand surgeon, you have ten fingers. So
Speaker 2: even if you know you don't have the great day
Speaker 2: in the oar, you still have nine fingers and most
Speaker 2: guys you get one penis. And therefore, like we got
Speaker 2: to be spot on, we gotta do. You can you
Speaker 2: can laugh while go on by Jordan, I mean that
Speaker 2: beautiful smile of yours. But yeah, we really, uh, we
Speaker 2: really do though. I mean, it's it's something that that
Speaker 2: you can't just jump in and shake your guy's hand
Speaker 2: and say I'll book you next Wednesday.
Speaker 3: So I think that's important.
Speaker 2: Talk to me about what you think if a guy
Speaker 2: comes in in a cute versus chronic phase. We've defined
Speaker 2: these and as you know from all the times we've
Speaker 2: been on stage to get everything else. I'm not a
Speaker 2: huge fan of acute and chronic in terms of six
Speaker 2: months to eighteen months or twelve months, or it's more
Speaker 2: sort of symptoms. But there is there a guy that
Speaker 2: it's too soon to operate on. How do you counsel
Speaker 2: somebody in terms of their disease state and what they've
Speaker 2: been through before they go to the OAR with you.
Speaker 4: Yeah, the dichotomy of active or acute versus chronic is
Speaker 4: kind of troublesome in a lot of ways, especially as
Speaker 4: we define who's a good candidate for surgery. You know,
Speaker 4: the guy who comes in and says, my symptoms started
Speaker 4: six weeks ago and I've noticed change over that period.
Speaker 4: That's not somebody where I'm going to feel enthusiastic about
Speaker 4: offering surgery. I usually like to just explain the rationale
Speaker 4: for waiting until we see things stay eyes. I feel
Speaker 4: comfortable with three months of stable symptoms, and you rely
Speaker 4: on the patient for that. It's not like I'm doing
Speaker 4: an assessment at three months, six months, nine months to
Speaker 4: prove that. I'm just explaining to the patient that if
Speaker 4: we operate too soon, you may still be in this
Speaker 4: period of active dynamic change and we may be operating
Speaker 4: on something before it's fully defined. Yeah, So I mean
Speaker 4: it's just generally probably around you know, six symptom duration
Speaker 4: of six months with stability for three months, So no
Speaker 4: change in your symptoms for three months. I feel pretty
Speaker 4: confident beyond that. But if at six months they say no,
Speaker 4: last month it was it was much better than it
Speaker 4: is today, I'm going to go hold on and we
Speaker 4: need to wait a little longer. So it is a
Speaker 4: it is a individualized decision.
Speaker 3: Yeah.
Speaker 2: I think that that that's the key as well for me,
Speaker 2: is that if if you go too soon, you could
Speaker 2: either undercorrect or overcorrect. If they're on any kind of therapy,
Speaker 2: that that may be changing this a little bit. And
Speaker 2: that that stable phase three month sounds like a pretty
Speaker 2: good time, And I think I don't. I don't have
Speaker 2: that exact cutoff either, but it just seems right and
Speaker 2: and I do. And you know, I'm sure you see
Speaker 2: the same patients that come in and say, you know,
Speaker 2: it took me forever to get in here, and I
Speaker 2: just you know, I got it.
Speaker 3: I need a plan, I need to do this now.
Speaker 2: And that's one of the things that we have to
Speaker 2: do in pernis is set those expectations and and so
Speaker 2: that's my next question for you, is how do you
Speaker 2: set expectations for Peroni's Because, as we talked about, I mean,
Speaker 2: this is you know, our our penis. The penis is
Speaker 2: such a it's such a big part of our identity
Speaker 2: and our psyche. And when we get Parone's disease, whether
Speaker 2: you get curvature or shortening or hourglassing or hinging, all
Speaker 2: the different form fruits that we've talked about on this
Speaker 2: on the show, then you're never going to get that
Speaker 2: same penis back. But how do you tell a guy,
Speaker 2: how are you going to get from where you are
Speaker 2: in my office miserable and life altered to the point
Speaker 2: where you're happy or at least satisfied with the outcome.
Speaker 2: Talk to me about expectations.
Speaker 4: The most important and the most challenging part of I
Speaker 4: think the practice. I mean, yes, the surgery is intricate,
Speaker 4: there are nuances to the non surgical treatments, but I
Speaker 4: think one of the most like one of the things
Speaker 4: that helps define a really good clinician in this space
Speaker 4: is is their ability to counsel patients, and one is
Speaker 4: to empathize with patients and just acknowledge that you know
Speaker 4: where you're at today and where you were at before
Speaker 4: this all started are two very different points. And unfortunately,
Speaker 4: and always say that up front, we're not going to
Speaker 4: get you back there. I mean, it's it's imperative that
Speaker 4: we emphasize that we don't want to. That just sets
Speaker 4: the wrong sort of the wrong tone if we If
Speaker 4: patient leaves my office and thinks, you know, I'm I'm
Speaker 4: going to get back the penis I had before, that
Speaker 4: doesn't mean there isn't a lot of hope and a
Speaker 4: lot of enthusiasm, but just acknowledging that upfront, and then
Speaker 4: I like to use the idea of you know where
Speaker 4: you're at today and you can think back to yesterday
Speaker 4: i e. When this all started and say that was
Speaker 4: a great place to be my that was a great penis.
Speaker 4: Now but now if we're going to talk about what
Speaker 4: I can do for you, we need to use today
Speaker 4: as the reference point. And so my goal is that
Speaker 4: tomorrow i e. After treatment, you say to yourself, I'm
Speaker 4: in a better place than I was today. And so
Speaker 4: that's the that's the counseling point that I've found lands
Speaker 4: with patients and I think it makes it makes intrinsic
Speaker 4: sense to me as well. Sometimes that's a really hard
Speaker 4: thing for patients to hear, and I mean we you know,
Speaker 4: we see tears sometimes. I mean, this is such a
Speaker 4: devastating thing for men. But at the end of the day,
Speaker 4: I think that you know, the many times those men
Speaker 4: once once they hear that, and they hear that you're
Speaker 4: still here to partner with them and there are still
Speaker 4: things that you can do, they still leave with help.
Speaker 4: And that's you know that for a better for a
Speaker 4: better life, a better penis a better better sexual function,
Speaker 4: better intimacy than they they're currently envying.
Speaker 2: Yeah, yeah, I think it's we always emphasize that we
Speaker 2: try to restore function, and that's that's the best expectation
Speaker 2: that I can set for any surgical candidate. And that's
Speaker 2: critical because there are guys that will never be able
Speaker 2: to kind of get back to where they were in
Speaker 2: their prime. And I find it's you know, sort of
Speaker 2: like talking with athletes, and you know that that when
Speaker 2: you were eighteen, when you were twenty two, you probably
Speaker 2: could throw a one hundred and two mile an hour fastball,
Speaker 2: and maybe by the time you got to twenty six,
Speaker 2: you started to lose a little velocity. But you know,
Speaker 2: can you go still play a good game of baseball
Speaker 2: when you're fifty?
Speaker 3: You know?
Speaker 2: I mean it's not the game you played when you
Speaker 2: were twenty five, but but you still got some some
Speaker 2: hunt and some fight left, pinion. And that's about the
Speaker 2: best we can do. So how do you how do
Speaker 2: you prepare somebody for surgery? And we're going to spend
Speaker 2: the last half of this. The next half of is
Speaker 2: just talking about the various options and who are candidates.
Speaker 2: But before you get to that point, talk to me
Speaker 2: about your pre opt talk your preparation. Do you talk
Speaker 2: about nutrition, hormone management, just you know, get somebody ready
Speaker 2: for your O war. If I'm flying all the way
Speaker 2: to Minnesota, I want to know you know what my
Speaker 2: soup and nuts are here?
Speaker 4: Yeah? Yeah, I mean the ultimately, the line I like
Speaker 4: to use is that if it's good for your heart,
Speaker 4: it's good for your penis. So generally, anything we can
Speaker 4: do to optimize your your general health status is going
Speaker 4: to optimize our outcomes with surgery. And that's particularly important
Speaker 4: as we're going to talk about with the sort of
Speaker 4: the most invasive surgery. But the you know, the plaque
Speaker 4: incision or partial black excision and grafting. But generally we
Speaker 4: want to optimize sexual function, which goes beyond just a
Speaker 4: straight penis or a straight or penis, and that starts
Speaker 4: with stress management, which is hard when patients are dealing
Speaker 4: with something stressful. Payerne's disease right not to mention everything
Speaker 4: else going on in their life. Starts with diet, starts
Speaker 4: with exercise, starts with sleep hygiene. All of those things
Speaker 4: aren't unique to Payne's disease. But every patient that we see,
Speaker 4: especially in the setting of sexual function and dysfunction, you know,
Speaker 4: probably has opportunities as do the rest of us, as
Speaker 4: does everybody. So like I like to have a conversation
Speaker 4: about that with all my patients, regardless of whether they're
Speaker 4: having surgery or not. You know, we generally like our
Speaker 4: patients to have a medical evaluation prior to considering a
Speaker 4: surgical intervention, just overall health and well being. But as
Speaker 4: far as penile health, yeah, I just spent some time
Speaker 4: counseling them about just lifestyle optimization, cardiovascular health and even
Speaker 4: psycho psychosexual health is another thing that you will make
Speaker 4: sure our patients all that you know, while yeah, in
Speaker 4: some ways I feel like, uh, you know, the glorified
Speaker 4: plumber sometimes, but uh, but we have experts who who
Speaker 4: can really help them, you know, identify other ways that
Speaker 4: there their psychological effect can be influencing the outcome we
Speaker 4: can get with surgery. So I have no no concerns whatsoever.
Speaker 4: In fact, encourage most patients to think about a psychosexual
Speaker 4: health EMIL if we have the time and resources to
Speaker 4: do so.
Speaker 3: H general health equals genital health.
Speaker 2: And just like a good plumber, you can tell people
Speaker 2: to keep potato peels out of your garbage disposal and
Speaker 2: prevent a lot of bad things. And so I think
Speaker 2: are I think keeping French fries to your diet maybe
Speaker 2: is the same thing new make sure you're startaway from
Speaker 2: ultra process foods and vacant calories and and that helps.
Speaker 2: But I love the fact that that you do what
Speaker 2: you do as as this surgeon, that people are coming
Speaker 2: literally from all over the world to have you operate them,
Speaker 2: and you still go with the fundamentals of eat, move,
Speaker 2: sleep and the mental health aspect of it, because I
Speaker 2: think a lot of these guys we deal with are
Speaker 2: emotionally devastated and it's amazing how few, even really high
Speaker 2: level Peroni thegnicians don't spend enough time at least when
Speaker 2: we're at these meetings talking about that mental health component.
Speaker 2: One of the biggest things about the show that we've
Speaker 2: I think it's evolved organically.
Speaker 3: Jordan, you can chime in.
Speaker 2: But but early on we had a therapist on that
Speaker 2: talked about the shame factor and men and we Stephen
Speaker 2: Polter was his name, and he he almost kind of
Speaker 2: framed a lot of what we talk about. The most
Speaker 2: of what we have to deal with in men's health
Speaker 2: deals with the idea of shame and Peroni I think
Speaker 2: is is target zero for that where you know, if
Speaker 2: you are used to as you were saying, you know
Speaker 2: your penis as it was yesterday, and then now you're
Speaker 2: in Siegelman's office today and it ain't the same penis
Speaker 2: it was yesterday, it's hard not to carry some shame
Speaker 2: about what happened, like did I do this to myself?
Speaker 4: Did you know?
Speaker 2: Did I do something wrong to get to this level?
Speaker 2: And we talked about that in a couple of previous
Speaker 2: episodes about do you know that there is this is a.
Speaker 3: Guilt free condition.
Speaker 2: It just happens like, you don't shame yourself if you
Speaker 2: get appendicitis. It's not because you had too many holopeno
Speaker 2: peppers or something. It's just, you know, it just happens
Speaker 2: and we have to take care of it. So I
Speaker 2: love that you. I love you hit all those and
Speaker 2: and so talk to me a little bit then about
Speaker 2: the physical prep. You know, so good nutrition, great, increase protein,
Speaker 2: increase your exercise, get your heart pumping. Do you do
Speaker 2: anything pino specific? I think I just made that word up.
Speaker 4: But I like it. I like it.
Speaker 2: Pinos specific track v D ahead of surgeries. Talk to me,
Speaker 2: I'm sorry, a vacuum erection device, I should say, or
Speaker 2: the Austin Powers chamber as we affect it.
Speaker 4: I U use that reference it. Uh, you gotta find
Speaker 4: your target demographic as far as knowing who's who's seen
Speaker 4: Austin Powers or not. But what a what a great
Speaker 4: reference point.
Speaker 3: We do?
Speaker 4: Yeah? I mean so, I'm a big proponent of mechanical
Speaker 4: mechanical therapy and that I basically tell patients as part
Speaker 4: of any treatment protocol, whether it's by itself or in
Speaker 4: combination with things like interllagional injections, like injections of ziaflex
Speaker 4: or or pre and or post surgical. I think that there,
Speaker 4: especially if we're sort of still defining you are you
Speaker 4: are you ready for surgery, either physically based on our
Speaker 4: criteria that we've set up for you know, who's a
Speaker 4: time wise who a good candidate, or just mentally some
Speaker 4: patients just aren't mentally quite there yet. And that's where
Speaker 4: mechanical therapy is doing something right. It's active, the patient's
Speaker 4: involved in it. It gives them time to literally it
Speaker 4: takes time, right, so it gives them time to focus
Speaker 4: on their penis, but also to kind of think about
Speaker 4: why they're doing this, like why are they putting in
Speaker 4: all this time and effort. And at the end of
Speaker 4: the day, the outcomes are that most men see enhanced elasticity,
Speaker 4: so more stretch on the penis. I hopefully that translates
Speaker 4: into more length. It's not necessarily what you've lost, but
Speaker 4: improve nonetheless, And lots of men see decrease in their curvature.
Speaker 4: So if anything, that's priming us to optimize our surgical outcomes,
Speaker 4: meaning if the curves a little less and we're going
Speaker 4: to talk about plication, right, maybe that means one less
Speaker 4: suit dra have to put in. If there's more elasticity,
Speaker 4: maybe when it's all said and done, their penis is
Speaker 4: able to stretch, or they're happier with the length, or
Speaker 4: they have less perceived length loss with the surgery. That's great,
Speaker 4: And regardless of what surgery we do, I encourage all
Speaker 4: patients to use traction afterwards. Not everybody takes us up
Speaker 4: on that, right, I mean, if they're happy with their
Speaker 4: outcome and they're ready to kind of move on from
Speaker 4: this awesome right, But for a lot of men who
Speaker 4: are really looking to optimize not only the straightness of
Speaker 4: the direction but also size, that's where doing traction post
Speaker 4: up is a great adjunct. And vacuum's fine too, It's
Speaker 4: just the data is more pronounced with or is more
Speaker 4: prominent with traction.
Speaker 2: Yeah, I mean, talk to me about the science of
Speaker 2: attraction a little bit, because I know a lot of
Speaker 2: this just came out of the Mayo clinic. So tell
Speaker 2: us about, you know, what's actually happening mechanically. Maybe even
Speaker 2: explain to Jordan and everybody else out there what attraction
Speaker 2: device is and because I'm sure everybody's googling it and
Speaker 2: then I can only imagine what comes up. But it's
Speaker 2: probably you know, if restauran is good at their SEO,
Speaker 2: they probably are coming up pretty high up in the liz.
Speaker 2: But yeah, talk to us about the science of what
Speaker 2: traction does to the penis.
Speaker 4: So this way oversimplified way to think about it is
Speaker 4: you're using a mechanical device to stretch the penis, right,
Speaker 4: and so with traction there's different mechanisms, but basically there's
Speaker 4: something that holds the head of the penis and then
Speaker 4: there's something that actually puts the flacid, so the non
Speaker 4: erect penis on stretch. And if you think about like
Speaker 4: stretching a muscle, right like I went for on this morning,
Speaker 4: my calf is tight. I'm going to stretch that calf
Speaker 4: out if I don't do that every day, and all right,
Speaker 4: stretch it for a while and it feels great, and
Speaker 4: then I say, okay, good, I'm done. I'm gonna stop.
Speaker 4: In a few days, my calf is going to be
Speaker 4: tight again. So it's kind of one of these things
Speaker 4: that you have to continue to do, probably definitely to
Speaker 4: really maintain those benefits. That's not what traction is intended
Speaker 4: to do. By stretching scar tissue the penis and I
Speaker 4: e the scar tissues. You're pulling pulling forces on the scar.
Speaker 4: There's actually good basic science evidence so in the lab
Speaker 4: where people actually did experiments on human tissue, on scar tissue,
Speaker 4: and they put that tissue on stretch and looked at
Speaker 4: the chemical makeup of that in the milieu or the
Speaker 4: like the environment that would happen in the body, and
Speaker 4: they found that there's actually structural changes that happened to
Speaker 4: the tissue. So certain enzymes which are sort of chemically
Speaker 4: active elements in the body, actually changed the structural makeup
Speaker 4: of that scar tissue. And to me, the ultimate outcome
Speaker 4: is more stretch, more elasticity. The scar tissue has more give,
Speaker 4: it's more appliable, and when somebody has an erection and
Speaker 4: their tissue is less restricted, they have less curve. Or
Speaker 4: if the whole area of scar tissue, which oftentimes much
Speaker 4: of the penis is involved in some degree in scar
Speaker 4: and loss of stretch, and you're gonna get more length back.
Speaker 4: It's not going to necessarily create the penis you had before.
Speaker 4: Not even not necessarily it will not create the penis
Speaker 4: you had before, but it can be a nice therapy.
Speaker 4: It's non invasive. You wear this device at home. The
Speaker 4: device Jesse that you'd recommended or discussed not recommended, that
Speaker 4: you referenced is the restore X, Right, that's one traction system,
Speaker 4: but there's others available. But you wear them anywhere from
Speaker 4: thirty minutes a couple of times a day to several
Speaker 4: hours depending on the device, for several months, and most
Speaker 4: men will get some mild but meaningful benefits from that.
Speaker 3: Yeah.
Speaker 2: Yeah, I've described too is if you know, when we
Speaker 2: wear braces, the braces don't straighten the teeth, The tensile
Speaker 2: woards remodel the bone around the teeth, and the teeth
Speaker 2: just kind of fall into place. And I think that
Speaker 2: kind of works a little bit for what's happened. I
Speaker 2: think you talked about this this fiber blast cascade that
Speaker 2: kicks in and allows a little bit more elasticity back
Speaker 2: to the healthy tissue around. Sometimes that's score unless you're
Speaker 2: doing something to the scar, which of course the combination
Speaker 2: of of interlegional therapy, which we had a whole discussion
Speaker 2: on earlier as well with with zieflex or some of
Speaker 2: the other non FT APPROOFD therapies. The idea is if
Speaker 2: you disrupt the scar, then you put a guy essentially
Speaker 2: in a splint. But it's you know, you can't really
Speaker 2: walk around with attraction device on. Although I had a
Speaker 2: guy try to get through TSA once with this years ago,
Speaker 2: and that turns out that that that went off, Like
Speaker 2: the TSA works as much as a much much as
Speaker 2: they say people are are wasting their time. Here's a
Speaker 2: guy walking through uh at traction with attraction device. He
Speaker 2: comes to my office, puts it on, and then goes
Speaker 2: back to wherever he comes from. And yeah, they actually
Speaker 2: pulled him out of line for that. So I don't
Speaker 2: recommend good to know that we are faster work exactly right,
Speaker 2: But but yeah, I mean it is something that you
Speaker 2: can wear. You can, but you can also overdo it too.
Speaker 2: Just for everybody listening out there, an hour is recommended.
Speaker 2: There is something called neuropraxia, which we've talked about in
Speaker 2: relation to prostate nerves and interrectile dysfunction, and neuropraxy can
Speaker 2: happen to the penis too. If if you go to
Speaker 2: sleep with these devices on, for example, that's a little
Speaker 2: bit not recommended because if you wake up in the
Speaker 2: morning and you have stretched those nerves on the door,
Speaker 2: some of the top aspect of the penis, you can
Speaker 2: get a little pen out numbnus.
Speaker 3: So sometimes too much is actually too much.
Speaker 2: And we was to put those guardrails on for our
Speaker 2: overly enthusiastic guys out there.
Speaker 3: They're going to run out and buy it.
Speaker 4: No, I think that's important because you know, the at
Speaker 4: least for the rhetorex like, one of the main outcomes
Speaker 4: for the initial study the randomized trial was safety. Right,
Speaker 4: patient said, can I wear this longer than thirty minutes
Speaker 4: at a time? And I say, from an efficacy and
Speaker 4: safety standpoint, I think thirty minutes is the key, those
Speaker 4: the max and then you take it off for a
Speaker 4: little bit and you give your penis arrest.
Speaker 3: There you go. That's right, all right, So let's hit this.
Speaker 2: Let's talk about now what surgeries are out there, who's
Speaker 2: a candidate for which one? And so kind of uh now,
Speaker 2: now pretend like I'm a fifty five year old guy
Speaker 2: in your office with with penal curvature, and then talk
Speaker 2: me through what are what are my surgical options? And
Speaker 2: and do I get to decide is it like a
Speaker 2: menu or or is there is there one kind of
Speaker 2: form of pernis that is better for one kind of surgery.
Speaker 2: So walk us through what my options are, Professor Ziegelman.
Speaker 4: Do we do we have like two or three hours?
Speaker 2: Yeah, exactly right, we have too our sponsors would love it.
Speaker 4: So so generally there are three, I mean, there are
Speaker 4: three kind of main mainstay approaches to Peroni's disease surgery,
Speaker 4: and I talk about these with all patients. There's a
Speaker 4: various forms of penal application, and the idea there is
Speaker 4: that you're you're essentially going to the opposite side of
Speaker 4: the curvature and you're using techniques, whether it's permanent or
Speaker 4: long acting sutures, or whether it's bringing tissue together, regardless,
Speaker 4: you're using techniques to basically restrict alongside from stretching to
Speaker 4: mimic what's happening on the side where the scar tissue is.
Speaker 4: In essence, you're shortening the erect the long side of
Speaker 4: the erect penis to account for the fact that scar
Speaker 4: tissue shortens the short side of the erect penis. It
Speaker 4: is a very reliable means. I mean, when we bring
Speaker 4: patients to the o R, we can get the penis
Speaker 4: within a few degrees of aerow straight in the operating room,
Speaker 4: and you know, the studies suggests, and I would say
Speaker 4: my experience plays us out that the long term success
Speaker 4: rates are excellent as far as maintaining that level of straightness. Now,
Speaker 4: just having a straight penis is not patient satisfaction in
Speaker 4: the long term for everybody, but that is if that's
Speaker 4: the goal, is to get the penis, you know, within
Speaker 4: a few degrees of straight as an arrow, and maintain
Speaker 4: that level of straightness, it's an excellent option. I will
Speaker 4: tell you that many patients have a little bit of
Speaker 4: a hard time with the idea that we're intentionally going
Speaker 4: in and shortening the long side of the penis and
Speaker 4: leaving that scar tissue alone. But at the end of
Speaker 4: the day, from an efficacy standpoint, it's an excellent option.
Speaker 4: So from getting the penis straight, it's a great option.
Speaker 4: Trade offs there, right.
Speaker 2: Yeah, I was going to say, al Morey's another legend
Speaker 2: in our field. He had a great line that I use,
Speaker 2: I think with every patient, which is that what we're
Speaker 2: doing is we're expanding the functional length of your penis
Speaker 2: because if you have if you have a severe curvature,
Speaker 2: you're an unable to engage in penetrative intercourse. Placation will
Speaker 2: allow you to engage and penetrative intercourse, so your functional
Speaker 2: and the functionality and the functional length is better. But
Speaker 2: there's no question that even if we do all kinds
Speaker 2: of relaxing incisions and techniques which which are reasonable to ask,
Speaker 2: you're certain if they do at the end of the day,
Speaker 2: that's exactly right. I mean, the physics or the geometry
Speaker 2: of this r too, is that you got to shorten
Speaker 2: the longside in order to get a straight penis. That's
Speaker 2: just a pythagorous at work.
Speaker 4: Yeah, I think when I've talked about it with land
Speaker 4: In Trust, another prominent member of our field. You know
Speaker 4: volume loss right, Like there's from a physics perspective where
Speaker 4: we're decreasing the volume of the erect penis regardless of
Speaker 4: the you know, it's hard, it's hard to measure an
Speaker 4: erection when it's curved like, so the true length of
Speaker 4: the erection. That's I don't never quote patients how much
Speaker 4: I'm going to shorten there, how much they're going to
Speaker 4: perceive their penis to be shortened, just because I don't.
Speaker 4: Their reference point is also the straight erection they had
Speaker 4: before this all started. Like entally, that's where your mind
Speaker 4: is going to go. It's going to go back to
Speaker 4: the last time I saw my penis straight, and that's
Speaker 4: a different penis, yep.
Speaker 3: Setting expectations. Yeah, all right, so placation.
Speaker 4: And application, and the other thing to just throw out
Speaker 4: there is that there are some men who have mild
Speaker 4: curvature but are bothered by narrowly right, So they've got
Speaker 4: their hour glass where the essentially circumferentially the penis is narrowed,
Speaker 4: or maybe one side is narrow and we call that indentation.
Speaker 4: And you can actually take a piece oftentimes using cadaver tissue,
Speaker 4: either human or some type of animal product, and actually
Speaker 4: molding it into those narrative areas. So from a visual perspective,
Speaker 4: we can restore the more of a natural circumference of
Speaker 4: the erection, so we can do that plaication surgery and
Speaker 4: then still still make the penis look a bit more
Speaker 4: consistent and quote unquote normal. So that's a nice option.
Speaker 2: I've been doing a lot of those too, I think
Speaker 2: you know, over the last few years, especially now that
Speaker 2: they're a little more cost effective options surgically to do
Speaker 2: what we call extra tunical grafting and the durability. I'm
Speaker 2: always surprised at how durable it is. But you know,
Speaker 2: I think what happens even after the graft is somewhat reabsorbed,
Speaker 2: it you just get this cylind You still maintain a
Speaker 2: lot of that cylindrical shape and help with that volume loss.
Speaker 2: It's not correct volume loss, but it is cosmetically volume loss.
Speaker 2: And yeah, it looks it's so much a nicer, more
Speaker 2: elegant outcome than the classic kind of puckering you get
Speaker 2: with a placating future. So so yeah, I'm I'm a
Speaker 2: big believer in extra tunical grafting with location as well.
Speaker 4: Yeah. The other sort of the next line as far
Speaker 4: as surgical intervention is either we call plaque incision or
Speaker 4: partial plaque excision, but it's basically going directly to the
Speaker 4: scar tissue and either making a full thickness cut through
Speaker 4: the scar or in some instances, for example, if you
Speaker 4: have calcium really get some people actually have chunks of
Speaker 4: essentially like bone in their penis, well we'll cut out
Speaker 4: a segment of the scar. Always patients, it's partial excision.
Speaker 4: We're not going in that the intention of removing all
Speaker 4: of the scar that you feel necessarily, we're going into
Speaker 4: straighten the penis. But the the idea there is you're
Speaker 4: releasing that restricted area as opposed to going to the
Speaker 4: opposite side and restricting it, so you're actually going to
Speaker 4: the point of the problem, which which you know, on
Speaker 4: paper always sounds like the nice option to do. The
Speaker 4: challenge comes in one the intricacy of the surgery that
Speaker 4: goes back all the way to the start of our conversation.
Speaker 4: I mean, that is a that is a case where
Speaker 4: you know, there's not that many of us, you and
Speaker 4: I and a few others who do a lot of these,
Speaker 4: and even then, I mean, what defines a lot is
Speaker 4: is somewhat variable, but the it's a it's a it's
Speaker 4: a challenging operation as far as just carrying out, but
Speaker 4: I think the more challenging part is just just mitigating
Speaker 4: the side effect. And those side effects, Yeah, the side
Speaker 4: effects with that surgery are neuropraxia. So it changes in
Speaker 4: penile sensation long term, and that's because especially for upward
Speaker 4: and side to side curves, there there's a tissue layer
Speaker 4: called the neuro vascular bundle, which essentially has the sensory
Speaker 4: nerves that supply sensation to the predominantly to the head
Speaker 4: of the penis and to get to the scar tissue
Speaker 4: which sits several layers deep, which I have to dissect
Speaker 4: tedious dissection lift those nerves up and off of the scar,
Speaker 4: which can be very challenging, especially if they've had other
Speaker 4: treatments like xyoplets for example. And you know, even in
Speaker 4: very experienced hands, when you're manipulating those nerves, there's going
Speaker 4: to be some tension on the tissue, et cetera. And
Speaker 4: so not everybody recovers full sensation or there's a risk
Speaker 4: of some sensation loss. Now, in you know, longer term
Speaker 4: studies which I would say are you know, defined as
Speaker 4: a year or greater, that risk is generally low, Like
Speaker 4: most studies, it's less than ten percent. I think in
Speaker 4: experienced hands is probably less than five percent. But it's
Speaker 4: not zero. It's not zero, and certainly we have patients
Speaker 4: who experience that. So that's one side effect to me.
Speaker 4: The more the bigger concern is rectile dysfunction after surgery.
Speaker 4: So there's a mechanism that allows your penis to trap
Speaker 4: blood during interaction. It's called the venal inclusive mechanism. I
Speaker 4: describe it as these microscopic veins that sit at the
Speaker 4: interface between where that scar tissue is and the blood
Speaker 4: filled the cavernosil body underneath the space that fills with
Speaker 4: blood during interaction, and those veins as the penis fills
Speaker 4: with blood, get compressed and they basically block the outflow
Speaker 4: that allows penis to maintain blood. And when you cut
Speaker 4: that scar and maintain the rigidity as the blood stays
Speaker 4: in the penis. When you cut that scar, I mean
Speaker 4: we're violating that mechanism. There's no way around that, right.
Speaker 4: We are injuring that mechanism where the scar tissue is located,
Speaker 4: and we do so in a piece of material, again
Speaker 4: usually a cadaver tissue into that area, which is supposed
Speaker 4: to be a scaffolding to allow the bodies normal tissue
Speaker 4: to grow in and recover that mechanism, but it doesn't
Speaker 4: always do that, and so there is a risk of
Speaker 4: rectile dysfunction after that surgery meaning soft directions meaning I
Speaker 4: didn't need pills before like viagrant siallis, and now I do,
Speaker 4: or meaning I didn't need pills before now viagran and
Speaker 4: cialis don't work, and I'm needing injections to help induce
Speaker 4: in direction, or I'm needing a surgery called a penole
Speaker 4: implant to allow my penis enough rigidity for intimacy. And
Speaker 4: so we've had patients where they've had excellent rigidity before
Speaker 4: surgery and unfortunately needed a penole implant after surgery. So
Speaker 4: we get their penis nice and straight and optimize the size,
Speaker 4: but again they're not maintaining rigidity at home, even with pills,
Speaker 4: then we have to bring them onto the next step.
Speaker 4: So that's that's a really tough outcome and it's one
Speaker 4: that thankfully is not the norm if we select the
Speaker 4: right patient for the right surgery, but it's one that
Speaker 4: I want all my patients to know as a possibility.
Speaker 4: And so I would talk through these options with them
Speaker 4: to say, you know, what if that happens to you,
Speaker 4: what would you do if if you're if if pills
Speaker 4: didn't work, would you think about injections? Would you think
Speaker 4: about an implant? If if the answer is no, no, no,
Speaker 4: that's not for me. That's not for me, I'm going
Speaker 4: to try to encourage them to think strongly about application,
Speaker 4: because yeah, we're you know, they may perceive their penis
Speaker 4: to be a bit shorter, but the surgery didn't in
Speaker 4: most instances, cause them to be non functional.
Speaker 2: Yeah, that's why I think of it. No, I think
Speaker 2: that's that's a key point. And there's a little bit
Speaker 2: you know of longitudinal data. Jerry Brock I think, has
Speaker 2: a really long study, since he's a couple years older
Speaker 2: than we are, and looking at the long term durability
Speaker 2: of black excision and grafting, and and it always is.
Speaker 2: The thing that kind of puts guys over the edge
Speaker 2: is when they lose a rectile function. And most of
Speaker 2: the time, thankfully in good hands, you're not talking about
Speaker 2: year one or year two, but by year five, year ten,
Speaker 2: you know, almost one hundred percent of guys after a
Speaker 2: black excision graph they've got ten years under their belt.
Speaker 2: Maybe they've developed worse cholesterol, maybe they've developed worse diabetes,
Speaker 2: worse blood pressure. But also, as you say, just the
Speaker 2: anatomy we fundamentally alter. At some point these guys are
Speaker 2: going to need that secondary surgery, which will be what
Speaker 2: you're probably going to talk about next. And I think
Speaker 2: that's critical. I love how you couch that, and I
Speaker 2: want people to think about that when they're having a
Speaker 2: consultation with a perni surgeon. Is what are you willing
Speaker 2: to do if this doesn't work. And I think that's
Speaker 2: brilliant what you just said, Matt, because I'm going to
Speaker 2: use that. I think it's fantastic, because I think we
Speaker 2: you know, we're doing this three sometimes I can take
Speaker 2: up to four hours to do one of these black
Speaker 2: excisions and graph surgeries. And you put all this into
Speaker 2: your heart and soul goes into it as a surgeon,
Speaker 2: and you only want the best outcome from your patient.
Speaker 2: And you know, six months, a year from now, if
Speaker 2: they still are having issues, you've got to go back
Speaker 2: to the conversation you had before you both went down
Speaker 2: that road together. And there's an old saying in surgery
Speaker 2: the last two people that want a second operation or
Speaker 2: the surgeon and the patient. You know, we we're not
Speaker 2: anymore or any less invested in your outcomes, especially if
Speaker 2: you go to a really good, high volume, conscientious surgeon.
Speaker 2: We want as good an outcome as the patient. And
Speaker 2: sometimes a PEG or a Plack decision graph or incision
Speaker 2: and graph. No matter what we do, we still are
Speaker 2: going to have work to do at the end of
Speaker 2: that three or four hours.
Speaker 4: Yeah, I totally agree with it, and I mean it
Speaker 4: is you develop a real relationship with these with these patients,
Speaker 4: and it's a longitudinal relationship. Like I tell them, we're
Speaker 4: in this together. But you're right, I mean, when you know,
Speaker 4: when we get that great outcome, which thankfully we get
Speaker 4: great outcomes with these surgeries, I certainly don't want to
Speaker 4: overemphasize the potential side effects. We get great outcomes, otherwise
Speaker 4: it wouldn't to be doing these, but it is. It is,
Speaker 4: you know, it's one we're all invested in, and the
Speaker 4: whole team is invested. And I think if you're if
Speaker 4: your surgeon isn't invested in that way, then probably you
Speaker 4: know a scenario where you want to find someone.
Speaker 3: Yeah, yeah you do.
Speaker 2: And I think that's the other thing is that that
Speaker 2: you mentioned it. But there aren't a lot of us
Speaker 2: doing a high volume number of plaque incision or plaque
Speaker 2: excision and grafting, and and it is because it's it's
Speaker 2: it's something you really have to either have incredible experience
Speaker 2: early in your career or have a Fellowship train background
Speaker 2: to do it, and and then to just keep keep
Speaker 2: up your reps to make sure you're able to elevate
Speaker 2: the neurovaskar the bundle well every time reliably and then uh,
Speaker 2: and then also what to do you know when you
Speaker 2: put that graft in and you still may have some
Speaker 2: other vascular work to do to get the guy perfect.
Speaker 2: I like how you how you put that, is that
Speaker 2: you want that that high volume, So talk to me.
Speaker 2: Then you mentioned it earlier, but I would say first
Speaker 2: of all to kind of sum up plaque excision graft
Speaker 2: is high. Good velocities are good. Pre pre surgical erectile
Speaker 2: function is one of the things that you need. Uh,
Speaker 2: maybe severely calcified graft where you can excize as much
Speaker 2: of that calcium but leave as much healthy tunica what
Speaker 2: we call tunicle sparing. Plaque incision excision grafting all good candidates.
Speaker 2: And if if a guy comes to you as a
Speaker 2: calcified plaque is only getting some degree of an erection
Speaker 2: with injection, has a curvature, say of fifty degrees sixty degrees,
Speaker 2: and he already has some baseline erectile dysfunction, talk to
Speaker 2: me about what you would do for that guy.
Speaker 3: Or and I don't mean to lead the surgeon here,
Speaker 3: but give me give me this.
Speaker 2: Talk to me about what you're going to do with
Speaker 2: the with already baseline erectile dysfunction, severe calcification deformity. Let's
Speaker 2: let's walk through those scenarios.
Speaker 4: Yeah. Yeah, And also, I mean that's you know, fifty
Speaker 4: degrees is and that's measure assuming we measure that in
Speaker 4: the office, is probably a bit of an underestimation to write.
Speaker 4: Many of these patients don't get quite quite the rigidity
Speaker 4: that they see at home or that they would with
Speaker 4: a full erection. So you know, that's one of us.
Speaker 4: That's a challenging scenario because you know, what we're going
Speaker 4: to be talking about here is is potentially a very
Speaker 4: definitive but also invasive surgery that's going to kind of
Speaker 4: be a big step. And the idea here is that
Speaker 4: this patient has a calcified scar, which we can go
Speaker 4: ahead and excize, we can cut that scar out, but
Speaker 4: also it's baseline erectile dysfunction, and that patient has no
Speaker 4: wiggle room, meaning if his erections are a little bit
Speaker 4: affected rigidity wise by the surgery to remove the scar,
Speaker 4: he's gonna he's going to be you know, he's going
Speaker 4: to have complete d he's going to correct correct, So
Speaker 4: he's got no you know, he's already on max dos
Speaker 4: PD five inhibitors ci allis viagra. I mean, we don't
Speaker 4: have any opportunity to, you know, to try those non
Speaker 4: invasive options, so then we're moving on to something more invasive.
Speaker 4: Right from the get go, there's a high likelihood that
Speaker 4: we're going to need something more and so that's a
Speaker 4: man I'm going to talk about something called a penal
Speaker 4: implant as part of the surgical treatment. Penal implant is
Speaker 4: a device that we place inside the erectile bodies that
Speaker 4: has the ability to essentially expand that space in the
Speaker 4: same way that blood would fill the space and create
Speaker 4: a strong, rigid erection that men can maintain as long
Speaker 4: as they want, whenever they want, without impacting their ability
Speaker 4: to urinate, to still should be able to achieve climax
Speaker 4: and ejaculation, et cetera. So it's really designed to provide
Speaker 4: on demand rigidity. There's another component called a pump, which
Speaker 4: replaced in the scrotum, and then a third component called
Speaker 4: the reservoir, which you can think of like a balloon,
Speaker 4: and that usually gets tucked behind the pubic boner under
Speaker 4: the abdominal muscle. And the whole ideas that you're you
Speaker 4: put fluid in the system and that fluid gets transferred
Speaker 4: into the penal tissues or into the you know, cylinders,
Speaker 4: creates that rigid direction. Obviously, these guys don't want to
Speaker 4: be walking around with a direction all day, most of them,
Speaker 4: at least maybe maybe North Dakota. Yeah, but the end
Speaker 4: of the they for those guys here, yeah, they move.
Speaker 4: There's a way to move that fluid into the water,
Speaker 4: you know, the sack the reservoir so that they can
Speaker 4: have more of a flaccid appearance. So that treats a
Speaker 4: rectile dysfunctioned very reliably. But if we're doing that surgery,
Speaker 4: we we also will address the curvature, we'll address the
Speaker 4: narrow and we'll adjust the calcified scar and then all
Speaker 4: those things that we were going to introduce as side
Speaker 4: or the main thing that we're going to introduce as
Speaker 4: a side effect, i e. Erectile dysfunction, we're now addressing.
Speaker 4: So you can do both of those at the same time.
Speaker 4: You can do that grafting surgery and know that I'm
Speaker 4: treating the ed that this surgery is likely exacerbating. It
Speaker 4: is a definitive treatment for erectile dysfunction and Payeronius disease,
Speaker 4: which many patients have simultaneously. Even for those men with
Speaker 4: less severe curves where you aren't or non calcified scar
Speaker 4: and you're not anticipating needing to do that plaque incision
Speaker 4: or excision, you can do the plycation where you put
Speaker 4: the future in. You can do something else called modeling,
Speaker 4: which is basically putting the device in and aggressively bending
Speaker 4: the penis opposite the direction of the curve, which can
Speaker 4: actually stretch and release some of those fibrous bands in
Speaker 4: the scar and correct the curvature. So there are opportunities.
Speaker 4: And if you have somebody a surgeon who does a
Speaker 4: lot of Perone's disease, they're going to have all of
Speaker 4: those tools in their tool belt to address the curvature
Speaker 4: during the penile implant surgery if needed, to get you,
Speaker 4: to get you a great outcome with respect to both
Speaker 4: the Erechtel dysfunction and the Parone's disease.
Speaker 2: Yeah, yeah, there's a great abstract. I can't remember. Maybe
Speaker 2: you remember at our last meeting just a couple months
Speaker 2: ago in DC on over dilation to help address that.
Speaker 2: You know, so most of the time, and this is
Speaker 2: super technical Jordan here jargon Jordan. But the Essentially, the
Speaker 2: idea is that when we put in penyle implants, we
Speaker 2: have to stretch out that tissue with with something called dilators,
Speaker 2: and there's a bunch of different ones, and we typically
Speaker 2: most of us that do a lot of penil implants
Speaker 2: go up to maybe twelve number twelve dilator.
Speaker 3: But if you go up a little bit.
Speaker 2: More, you can actually manually manipulate that scar tissue and
Speaker 2: break up some of those bands. So it's almost like
Speaker 2: pre modeling because the cylinders himself act as it beams.
Speaker 2: If you put in a rigid enough cylinder that can
Speaker 2: really hydraulically fill up to the twenty five plus to
Speaker 2: thirty psi even if you really really pump. But I
Speaker 2: think that's interesting too, is this aggressive dilation. Because you're right,
Speaker 2: and if you do a plaque excision in graph and
Speaker 2: an implant in the same day. First of all, it's
Speaker 2: a long surgery. We know that the complications are accumulative
Speaker 2: with that, but man, what a home run operation if
Speaker 2: you can, if you can do it in the right candidates,
Speaker 2: that's super healthy. Definitely, I would never consider anybody that
Speaker 2: has uncontrolled diabetes, hypertension, anything that could affect wound healing,
Speaker 2: history of radiation therapy to the pelvis. But the ideal
Speaker 2: candidate that has just isolated severe peyronies and erectile disfunction
Speaker 2: but otherwise is healthy. That that is your your perfect
Speaker 2: candidate to try to do both at once. But yeah,
Speaker 2: there's so many other maneuvers that we can do short
Speaker 2: of doing that that black excision graph plus IPP at
Speaker 2: the same time. But yeah, that is kind of like oof,
Speaker 2: that's in that's our that's our twelve point bucket. You'll
Speaker 2: have to be able to do that on the same day.
Speaker 4: It is a I mean that it is a significant recovery,
Speaker 4: like for g I mean just a plaque incision or
Speaker 4: plaque excision and graft those guys from I mean there's
Speaker 4: a lot of healing that happens in the penis during
Speaker 4: the first several months, but impact on their day to
Speaker 4: day life usually about a couple of weeks. They're like
Speaker 4: rocking and rolling.
Speaker 3: Yeah, good point.
Speaker 4: But in a pen l implant, Yeah, some of those
Speaker 4: guys can be extremely sore for you know, two to
Speaker 4: four weeks and there's definitely a there's a lot swelling
Speaker 4: and there's a recovery there. But if you come bine
Speaker 4: those two. I just always emphasize it that's it's gonna
Speaker 4: be a rough six weeks, we're gonna get you there.
Speaker 4: But it's it's a it's a big, much bigger recovery.
Speaker 4: To do the two together. It's oftentimes the right thing
Speaker 4: to do in the in the right patient, but there's
Speaker 4: there's also it's also a reason that if somebody is saying,
Speaker 4: I really want to do the grafting surgery, and I
Speaker 4: understand that I may not be the ideal candidate, but
Speaker 4: I want to see if I'm in that fifty percent
Speaker 4: who's going to maintain my rectile function for several more years,
Speaker 4: and I'll think about it down the line, or if
Speaker 4: in six months I need it. I mean, there are
Speaker 4: you know, there is that's two surgeries, but the recovery
Speaker 4: cumulative is probably still easier on that person than the
Speaker 4: two together. And so I certainly I've done that and
Speaker 4: have had conversations with patients about that. Larry Levine had
Speaker 4: a paper I don't know if it's if it's out yet,
Speaker 4: but it was accepted for discussing No no, this one's
Speaker 4: a couple of years old now, but it was describing
Speaker 4: patients who he recommended do an implant, but they decided
Speaker 4: to go with a graft after appropriate counseling, and it
Speaker 4: was about a fifty eight percent risk of rectile dysfunction
Speaker 4: that was essentially a refractory to oral medication, so higher
Speaker 4: than we would expect in a standard population of men
Speaker 4: with good rectile function, But fifty to fifty some guys
Speaker 4: who are really trying to divide that implant, they may
Speaker 4: still be willing to take those odds.
Speaker 3: Yeah, I think that stage procedure.
Speaker 2: It also gives guys a chance to do traction and
Speaker 2: potentially end up if you stage it. Even if it's
Speaker 2: staging by one to two years, Like you said, fifty
Speaker 2: percent of those guys were able to get erections with
Speaker 2: maybe injections, pills, traction that you might be able to
Speaker 2: come back and put in a better implant than you
Speaker 2: could at the same time. So I think that's a
Speaker 2: really nice stutter step and another very nuanced aspect of
Speaker 2: our counseling. So we have this section, Professor Ziegelmann, we
Speaker 2: do pretty much every time called you're probably going to
Speaker 2: be okay, and once somebody is going to actually say, actually, no,
Speaker 2: you're not going to be.
Speaker 3: Okay, but to date today.
Speaker 2: Maybe it's because I phrased the question with the case
Speaker 2: scenario where we leave our audience with hope and the
Speaker 2: future of a better day. But let me go through
Speaker 2: this case scenario. A fifty five year old guy, because
Speaker 2: you're probably going to see this in your office in
Speaker 2: this week, maybe two or three times comes into you.
Speaker 2: He had zyaflex, which is the intra regional collagen. As
Speaker 2: we had a whole episode on about maybe he started
Speaker 2: with a seventy degree curvature dorsal, meaning up towards his
Speaker 2: belly button curve, really difficult having intercourse. He had some
Speaker 2: calcifications within the plaque, but still was able to get
Speaker 2: about a fifty, well twenty degree improvement. So he's left
Speaker 2: with fifty degree dorsal, has really good rigid erections.
Speaker 3: Otherwise super healthy.
Speaker 2: He's a triathlete and fantastic shape, no diabetes, good blood pressure,
Speaker 2: still has fifty degrees. After this, he also noticed some
Speaker 2: length loss and maybe his eyeflex in traction helped get
Speaker 2: him back a centimeters or so. But he's very very
Speaker 2: conscious about his length and his penal dysmorphism where he
Speaker 2: just never could look at his penis the same way again.
Speaker 2: So he's so bothered by this that that's very difficult
Speaker 2: for him to even think about intercourse again. Even though
Speaker 2: he had you know, a reasonable expectated or expection improvement
Speaker 2: with zyoflex, he still has a curvature. What are you
Speaker 2: going to do for this guy? And is he going
Speaker 2: to be okay? Are you going to like, hey, let's
Speaker 2: do some more zyaflex. You got a little bit of
Speaker 2: an improvement. Maybe I have a better technique than where
Speaker 2: you came from. Tell me about this guy. Now, he's
Speaker 2: been at this for now for almost two years in
Speaker 2: this journey, and you know, almost six months of that
Speaker 2: was an act of therapy with zyaflex.
Speaker 3: He wants an answer.
Speaker 2: He's coming all the way to Rochester for you to
Speaker 2: take care of him.
Speaker 4: Yeah, I would say the jet I'm not gonna I'm
Speaker 4: not going to buck the trend here. Yes you are
Speaker 4: going to be okay? Yeah, there we go. No, there's
Speaker 4: I still think this this is Yeah. We see patients
Speaker 4: with a similar experience all the time, severe curvature to
Speaker 4: start wanting to try something non surgical upfront, which I
Speaker 4: think is very appropriate, and had some response to that treatment.
Speaker 4: But still bothered by the residual curve. And that's that's
Speaker 4: actually a challenging in some ways because you're going you
Speaker 4: you you prove to us that you're a responder to ziaflex.
Speaker 4: So there's nothing you know, you've you've had your eight injections,
Speaker 4: but there's nothing to say that that. I had no
Speaker 4: data that I know of that says you're you're not
Speaker 4: going to continue to have some incremental response if we
Speaker 4: and in fact, I think there is data I think
Speaker 4: even your experience. Yeah, yeah, that says you can continue
Speaker 4: to have an incremental response with additional zioflex. So if
Speaker 4: somebody is looking to you know, minimize the potential side
Speaker 4: effect risk of surgical interventions was okay. Did find in
Speaker 4: the recovery it wasn't too impactful on his life as
Speaker 4: far as the coming in and back and forth to
Speaker 4: the clinic, doing the stretching, et cetera. I would absolutely
Speaker 4: consider that person a candidate to continue on with another
Speaker 4: you know, cycle series, full treatment course of zyaflex, knowing
Speaker 4: that at any point we can you know, cut bait.
Speaker 4: One of the challenges it's just making sure that we
Speaker 4: get insurance approval for that. But you know, all the
Speaker 4: things created equal, that'd be very appropriate. That being said,
Speaker 4: if they've gone through the ziaflex, they're ready to move
Speaker 4: on to a surgical treatment. This this is where that
Speaker 4: expectation setting comes in those patients who are really bothered
Speaker 4: by their loss of penal length. Just emphasizing what is
Speaker 4: the goal with surgery, right, It's function over fashion, It's
Speaker 4: restoring the or impress should say, improving intimacy by enhancing
Speaker 4: sexual function by straightening the penis and so yes with
Speaker 4: for example, plaque incision. In a setting like this, in theory,
Speaker 4: we're releasing the restricted area. The reason that men perceive
Speaker 4: and actually lose length on the direction is a lot
Speaker 4: more complicated than just that one area where the scar
Speaker 4: tissue is causing the curature. So I think I really
Speaker 4: spend a lot of time with these in the setting
Speaker 4: emphasizing what the goals of surgery are and that most men,
Speaker 4: at least in my experience, are not perceiving their penis
Speaker 4: to be longer after that surgery. They may actually still
Speaker 4: perceive their penis to be shorter again because of that
Speaker 4: perception versus reality. You know, what was the baseline of
Speaker 4: rectile length before the self started versus you know, after
Speaker 4: we're done, et cetera. But ultimately that patient may be
Speaker 4: goodcademies healthy, he's got still residual modern to severe curvature.
Speaker 4: If he understands the risk, benefits and alternatives, I'd be
Speaker 4: I would consider him a candidate for incision and grafting.
Speaker 4: That being said, I would also talk about placation and
Speaker 4: really emphasize the functional improvements that can be had with
Speaker 4: straightening the penis and the trade offs as far as
Speaker 4: side effect profile and the you know, potential ed risk,
Speaker 4: et cetera. Because this is a guy where you know,
Speaker 4: if you do if he is, you know, if he
Speaker 4: does develop D like that could be a lot more
Speaker 4: devastating than perceiving a little bit of extracise loss. So
Speaker 4: it's just setting expectations. But ultimately this is shared decision making, right.
Speaker 4: I'm not going to talk this patient and this is
Speaker 4: a great candidate for any of those treatment options, and
Speaker 4: I'm not going to try to talk him in, and
Speaker 4: I don't want him to perceive that I'm talking him
Speaker 4: into any therapy. I'm going to offer you the best
Speaker 4: outcome we can with any of these options. Answer.
Speaker 2: Sorry for that, beautiful, I believe that you've for the
Speaker 2: reason that that you know you you could he would
Speaker 2: be a candid for all of that with excellent decision making,
Speaker 2: and he had to wrap up. What you were saying
Speaker 2: is that we looked at this years ago, I think
Speaker 2: is around twenty nineteen we published this, but it's you know,
Speaker 2: guys that do well with the eight the eight injections.
Speaker 2: About eighty percent of guys at least in our experience,
Speaker 2: had a very satisfactory outcome with that. So the twenty
Speaker 2: percent of guys that we looked at for second round,
Speaker 2: and that numbers actually migrated up is around twenty three
Speaker 2: percent now, but still you know, twenty say percent of
Speaker 2: guys had about a twenty degree improvement, which is lower
Speaker 2: than what the impressed trials would say, which which was
Speaker 2: what got FDA approval for Ziefflex about thirty four to
Speaker 2: thirty five percent. So we had some recalcitrant plaques I
Speaker 2: call them, that that would go on to a second round.
Speaker 2: So of those twenty percent that didn't get a great
Speaker 2: outcome with that first round of Eyefflix, by the time
Speaker 2: we did two rounds or a fraction of two rounds,
Speaker 2: so somewhere between twelve and sixteen injections, they developed about
Speaker 2: a fi fifty percent improvement. And so you're right, this
Speaker 2: guy if we went from seventy down to fifty, but
Speaker 2: then if we went fifty to twenty five, he all
Speaker 2: of a sudden has the curvature that would most guys
Speaker 2: would be easily about that penetrator and intercourse. And so
Speaker 2: that's why we did this whole thing on surgery. And
Speaker 2: then I had you come up with a case scenario
Speaker 2: where he might be okay with just perseverance and and
Speaker 2: another potential other around his eyeflex. But yeah, guy's also like, look,
Speaker 2: you know what, I don't have the time for this.
Speaker 2: Then you could start talking, because I've certainly had guys
Speaker 2: that you're just like, I don't love getting injections, and
Speaker 2: you know, it's cumbersome and it's uncomfortable. And if you
Speaker 2: can do a surgery where I can get in and
Speaker 2: out of your oar in an hour or three, then
Speaker 2: then let's talk about that now, Professor Zieglmann. So so
Speaker 2: that's exactly why I so you're going to be okay.
Speaker 2: I mean, that's the most important thing with anything peronis
Speaker 2: related is we're going to find a way to get
Speaker 2: back your functionality. So we have to close always with
Speaker 2: this question that I ask all of my guys, and
Speaker 2: you already mentioned it today.
Speaker 3: Already.
Speaker 2: It's a couple hours later in Minnesota than it is
Speaker 2: in Santa Monica, so you already went up for your
Speaker 2: run for the day. But without leading you again, what
Speaker 2: is it that you do every day? Because you're a dad,
Speaker 2: you're a husband. I mean, you have so many things
Speaker 2: in your life to make you show up every day
Speaker 2: as well as you can tell me, tell me the
Speaker 2: hit list, and make Professor Ziegelman the dude he is.
Speaker 4: Yeah, so it's a wonderful question. Actually, you you prompted
Speaker 4: me about this a couple of days ago, so I
Speaker 4: had some time to think too. Sorry if I'm giving
Speaker 4: away it's yeah. So I every every morning, uh, you know,
Speaker 4: unless there's some very extenuating circumstances, I try to get
Speaker 4: up and do self care and for me that's usually cardio.
Speaker 4: At cardio, uh, I do either run or bike. And
Speaker 4: being in Minnesota, you can imagine in the winter, a
Speaker 4: lot of that is indoors. Yeah, but you know what,
Speaker 4: one of my other loves is TV and movies, and
Speaker 4: so I can get through uh TV show and or
Speaker 4: a couple of movies a week doing some indoor you know,
Speaker 4: running and cycling, which is great, so it gets to
Speaker 4: be ready for the day. Yeah, yeah, exactly. I do
Speaker 4: the same thing.
Speaker 2: Love yeah, I love on a treadmill watch in a series,
Speaker 2: and it makes makes the pain and the TDM so better.
Speaker 4: Totally.
Speaker 2: I get to run outside all the time here. But
Speaker 2: but I, but I don't get that same level of
Speaker 2: habit stacking. Although I listened to books on tape when
Speaker 2: I run, so it kind of helps. But say I
Speaker 2: just have books on tape. Jordan's help me. Can you
Speaker 2: fix that? And say audio books?
Speaker 4: That's still call the books on tape.
Speaker 3: Well, if we all talk about Austin powers were men.
Speaker 4: I still have a I still have a CD player.
Speaker 4: You know, I still.
Speaker 3: Can't Jordan and I swap eight tracks. It's pretty good, real, real, Jordan,
Speaker 3: you've been so quiet. I I want to get doctor r.
Speaker 2: Ziglemann off of his days, since he delivered so famously
Speaker 2: on the mail Room. But any closes thoughts about questions,
Speaker 2: You maintain your color throughout an entire surgical discussion about
Speaker 2: disassembling and reassembling penises, So congratulations.
Speaker 4: Than we have the pictures. We have pictures.
Speaker 3: Exactly right, Yes, I mean sent me the deck through
Speaker 3: the email. Yeah, yeah, yeah, I mean I.
Speaker 5: Think the only question I had and this was you
Speaker 5: answered a lot of my physiological questions. And I had
Speaker 5: a couple of psychological questions that maybe we could say
Speaker 5: for another day, but just this kept popping back into
Speaker 5: my head. The uh implant you said was I think
Speaker 5: the phrases use was sort of on demand rigidity that
Speaker 5: would fill with with saline or whatever the fluid is.
Speaker 3: How is that triggered?
Speaker 4: Yeah, yeah, yeah, I wish it was on an app
Speaker 4: on your phone up here, but someday, someday. That's what
Speaker 4: we've been hearing. It's called a pump, and it's put
Speaker 4: in your scrotum, so your scrotum is like your sack, right,
Speaker 4: and it's put it between the testicles, either in front
Speaker 4: or behind, depending on and you actually the guy learns
Speaker 4: to squeeze the pump, so it's like it kind of
Speaker 4: almost feels in some men like a like a firm
Speaker 4: third testicle, Not really, but I mean, and then you
Speaker 4: squeeze that and that actually generates generates the fluid transfer
Speaker 4: from that reservoir, the little water balloon behind the pubic
Speaker 4: bone up into the penis.
Speaker 3: Wow, it's magic.
Speaker 2: We're going to have a whole series on pen l implants,
Speaker 2: so yeah, good, awesome, good foreshadowing for that. But it
Speaker 2: is truly a revolutionary device. It's you know, relatively new.
Speaker 2: It's only been out since about nineteen seventy two, so
Speaker 2: so yeah, we got some learning to do their young,
Speaker 2: young Jordan.
Speaker 5: I don't know anything past Vinyl, so any technology past
Speaker 5: nineteen seventy I'm excited.
Speaker 2: We got your brother, we got you. Well, Matt, thank
Speaker 2: you so much for coming on the mailroom. This has
Speaker 2: been great. You've definitely entertained as well as educated our audience,
Speaker 2: and I hope you continue to do the amazing work
Speaker 2: you're doing for guys every were with your with your career,
Speaker 2: which again to chief professor level at your young age
Speaker 2: is truly an accomplishment. So I want to shout that
Speaker 2: out that that's that's truly remarkable work and dedication to
Speaker 2: your craft. So congrats, and then maintaining your cardio through
Speaker 2: the whole thing.
Speaker 4: Yeah, I appreciate it. Yeah, well, thank you, this has
Speaker 4: been This has been great. Nerding out on Pironi surgery. Yeah,
Speaker 4: it's nothing better on the Monday.
Speaker 2: That's right, We're doing it, all right, all right, Well
Speaker 2: we'll see at the next meeting. Have a great summer,
Speaker 2: and thanks again for dedicating an hour of your time
Speaker 2: to help guys everywhere.
Speaker 3: All right, Thank you, Jordan. We nailed it. Another one
Speaker 3: for the books.
Speaker 4: We got it. You delivered on the mail room of
Speaker 4: my friends.
Speaker 3: Thank you.
Speaker 4: Cool. Let's talk about it.
Speaker 1: Let's talk about him a man, Let's talk of a
Speaker 1: Malom's Talk about.
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